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Request Medical Records Michigan Pain Consultants

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Need to Request a Copy of Medical Records from MPC?

To initiate getting records, submit a signed and dated Authorization for Use or Disclosure of Protected Health Information to the clinic.  The form may be obtained at the clinic, or through this link:


After you complete and submit the form to the clinic, it is reviewed by the clinic staff and put in your file. Your request is processed by BACTES Imaging Solutions, our HIPAA Business Associate.

Some requests are processed at no charge to the requesting party (such as referrals for continuing care).  Other requests are charged a fee, in accordance with state statutes. BACTES bills requesting entities such as attorneys, insurance companies, etc. directly; patients are not billed for this work.

Patients who request records for their personal use or for transferring to another pain clinic, or similar provider, will be charged a fee.  This explained in the fee for records letter available at the clinic or at above link.

BACTES processes the requests and delivers an invoice detailing the fee for the requested records.  Upon receipt of payment, BACTES delivers a copy of the records to the requestor.

Please allow 7 business days after your forms have been accepted by MPC for processing and delivery of the invoice.

After 7 business days, patients with questions on the status of their request should call the BACTES center for personal medical records requests (248) 977-3926.

After 7 business days, attorneys, insurance companies, etc. with questions on the status of their request should call the BACTES center for third party medical records requests (800) 560-3800.

Need to Send a Copy of Medical Records TO MPC?

New and returning patients often need to have certain medical records sent to MPC to assist in their diagnosis and treatment.  If you need your current (or previous) provider to send your records to MPC, a request form may be obtained at the clinic, or through this link:


Do you need help with where the info should be sent? Please check with MPC clinic staff to obtain the mailing address for where your records should be mailed.

Need to Request Completion of an FMLA form?

To avoid delays in processing your request, please read this section in its entirety.  Address any questions you have to the MPC clinic.

To initiate the process, complete all of the information (including signatures and dates) in the required employee/patient section of the FMLA form.

Complete the Authorization for Use or Disclosure of Protected Health Information. The form may be obtained at the clinic, or through this link:

When completing this form, be sure to include:

  • The reason(s) for the leave (e.g., flare-ups of existing condition, medical treatments, day after medical treatments, current disability, transportation of a spouse requiring treatment, etc.);
  • The period of leave required (e.g., six weeks continuous, 1-2 days per month, etc.); and
  • The beginning and ending dates for the leave

Submit both the FMLA form and the Authorization form to the clinic where it is reviewed by the clinic staff and put in your file. To offset the increasing costs associated with this service, a fee of $25.00 is required at the time the paperwork is submitted.  This fee must be paid prior to the completion of your request.

Due to the time sensitivity of FMLA requests, no invoices will be sent. A letter explaining the fee and where to send payment may be obtained at the clinic, or at the above link.

Your request is processed by BACTES Imaging Solutions.

Please allow 10 business days after your payment has been delivered AND the forms have been accepted by MPC for processing and delivery.

After 10 business days, patients with questions on the status of their request should call the BACTES center for FMLA requests (248) 977-3926.

Need to Request Completion of a Disability form?

To avoid delays in processing your request, please read this section in its entirety.  Address any questions you have to the MPC clinic.

To initiate the process, complete all of the information (including signatures and dates) in the required employee/patient section of the Disability form.

Complete the Authorization for Use or Disclosure of Protected Health Information.  The form may be obtained at the clinic, or through this link:

When completing this form, be sure to include:

  • The reason(s) for the disability (renewal of disability for an ongoing condition, a new condition - be sure to describe the reason(s) leave Is needed);
  • The period of disability (e.g., six weeks continuous, indefinite, etc.); and
  • The beginning and ending dates for the disability

Submit both the Disability form and the Authorization form to the clinic where it is reviewed by the clinic staff and put in your file. To offset the increasing costs associated with this service, a fee of $25.00 is required at the time the paperwork is submitted.  This fee must be paid prior to the completion of your request.  Due to the time sensitivity of Disability requests, no invoices will be sent; payment is the patient’s responsibility. A letter explaining the fee and where to send payment may be obtained at the clinic, or at the above link.

Your request is processed by BACTES Imaging Solutions.

Please allow 10 business days after your payment has been delivered AND the forms have been accepted by MPC for processing and delivery.


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